Fluidoterapia en el Paciente

Criticamente enfermo

MR. MARIO M. MARCHAND GONZALES

MEDICINA INTENSIVA
 INTRODUCCIÓN

Jean-Louis Vincent and Daniel De Backer. Circulatory Shock. N Engl J Med 2013;369:1726-34. DOI: 10.1056/NEJMra1208943
 INTRODUCCIÓN

Jean-Louis Vincent and Daniel De Backer. Circulatory Shock. N Engl J Med 2013;369:1726-34. DOI: 10.1056/NEJMra1208943
FISIOLOGÍA DE LA ADMINISTRACIÓN
DE FLUIDOS
VENA ———> Predomina P oncótica

ARTERIA ———> Predomina P hidrostática

GLYCOCALYX ENDOTELIAL: Capa compleja

con múltiples funciones; consiste en glicoproteínas
y proteoglicanos en el lado luminal, que
desempeñan un papel clave en la regulación de la
permeabilidad vascular.

Timo Mayerhöfer, Andrew D Shaw, Christian J Wiedermann, Michael Joannidis, Fluids in the ICU: which is the right one?, Nephrology Dialysis
Transplantation, Volume 38, Issue 7, July 2023, Pages 1603–1612
 FISIOLOGÍA DE LA
ADMINISTRACIÓN DE FLUIDOS

Timo Mayerhöfer, Andrew D Shaw, Christian J Wiedermann, Michael Joannidis, Fluids in the ICU: which is the right one?, Nephrology Dialysis
Transplantation, Volume 38, Issue 7, July 2023, Pages 1603–1612
 FISIOLOGÍA DE LA
ADMINISTRACIÓN DE FLUIDOS
CAPACITANCIA VENOSA
REDUCE EL VOLUMEN INTRAVASCULAR

PERDIDA DE LÍQUIDOS
*Retorno venoso
*Gasto Cardiaco
*Perfusión Tisular

RESISTENCIA VENOSA

Peter Pickkers Et al. Acute kidney injury in the critically ill: an updated review on pathophysiology and management. Intensive Care Med (2021) 47:835–850
https://doi.org/10.1007/s00134-021-06454-7
Zampieri FG, Bagshaw SM, Semler MW. Fluid Therapy for Critically Ill Adults With Sepsis: A Review. JAMA. 2023;329(22):1967–1980.
EVALUACIÓN PARA LA TERAPIA DE
FLUIDOS
 TOLERANCIA A LOS FLUIDOS

Hortencio Rafael et al. Beyond fluid responsiveness: the concept of fluid tolerance and its potential implication in hemodynamic management. Crit Care Sci. 2023;35(2):226-229. DOI:10.5935/2965-2774.20230012-en
 TOLERANCIA A LOS FLUIDOS

ELEVACIÓN PASIVA DE PIERNAS

Aumentó de GC tras bolo de fluidos (E:92%)
(S:88%)

Hortencio Rafael et al. Beyond fluid responsiveness: the concept of fluid tolerance and its potential implication in hemodynamic management. Crit Care Sci. 2023;35(2):226-229. DOI:10.5935/2965-2774.20230012-en
 TOLERANCIA A LOS FLUIDOS

Peter Pickkers
Giuseppe Mancia(Chairperson)
Et al. Acute kidney
Et injury
al. 2023
in ESH
the critically
Guidelinesill: for
an updated
the management
review onofpathophysiology
arterial hypertension.
and management.
The Task Force
Intensive
for theCare
management
Med (2021)
of arterial
47:835–850
hypertension of the European Society of
Hypertension ERA/ISH. DOI:10.1097/HJH.0000000000003480
https://doi.org/10.1007/s00134-021-06454-7
Finfer, S., Myburgh, J. & Bellomo, R. Author Correction: Intravenous fluid therapy in critically ill adults. Nat Rev Nephrol 14, 717 (2018).
ADMINISTRACIÓN DE FLUIDOS
Timo Mayerhöfer, Andrew D Shaw, Christian J Wiedermann, Michael Joannidis, Fluids in the ICU: which is the right one?, Nephrology Dialysis
Transplantation, Volume 38, Issue 7, July 2023, Pages 1603–1612
FASES DE LA ENFERMEDAD
CRÍTICA

Finfer, S., Myburgh, J. & Bellomo, R. Author Correction: Intravenous fluid therapy in critically ill adults. Nat Rev Nephrol 14, 717 (2018).
Finfer, S., Myburgh, J. & Bellomo, R. Author Correction: Intravenous fluid therapy in critically ill adults. Nat Rev Nephrol 14, 717 (2018).
FASES DE LA ENFERMEDAD CRÍTICA

PVC = 8-
12mmHg
PAM= 65-90
SatVO2=
>70%

Restrictivo Liberal
1,2L +- vasopresor 3,4 L

No diferencia significativa en torno a la MORTALIDAD

N:1563 (14% vs 14.9%) p=0.61

Zampieri FG, Bagshaw SM, Semler MW. Fluid Therapy for Critically Ill Adults With Sepsis: A Review. JAMA. 2023;329(22):1967–1980.
FASES DE LA ENFERMEDAD CRÍTICA
CLASSIC

1554 adultos gravemente enfermos

Manejo restrictivo VS estándar

PERFUSIÓN de órganos y tejidos

BOLOS:
- Lactato >4mmol/L
- PAM <50 mmHg
- Moteado sobre la rótula
HOMEOSTASIS y resolución de la - Diuresis <0.1 ml/kg/h
disfunción orgánica

Mortalidad 90 días (42.3 VS 42.1%)

- 1627ml menor administración

Zampieri FG, Bagshaw SM, Semler MW. Fluid Therapy for Critically Ill Adults With Sepsis: A Review. JAMA. 2023;329(22):1967–1980.
TIPO DE FLUIDO
Finfer, S., Myburgh, J. & Bellomo, R. Author Correction: Intravenous fluid therapy in critically ill adults. Nat Rev Nephrol 14, 717 (2018).
Finfer, S., Myburgh, J. & Bellomo, R. Author Correction: Intravenous fluid therapy in critically ill adults. Nat Rev Nephrol 14, 717 (2018).
Finfer, S., Myburgh, J. & Bellomo, R. Author Correction: Intravenous fluid therapy in critically ill adults. Nat Rev Nephrol 14, 717 (2018).
Timo Mayerhöfer, Andrew D Shaw, Christian J Wiedermann, Michael Joannidis, Fluids in the ICU: which is the right one?, Nephrology Dialysis
Transplantation, Volume 38, Issue 7, July 2023, Pages 1603–1612
Timo Mayerhöfer, Andrew D Shaw, Christian J Wiedermann, Michael Joannidis, Fluids in the ICU: which is the right one?, Nephrology Dialysis
Transplantation, Volume 38, Issue 7, July 2023, Pages 1603–1612